In the United States, the impact of an aging population makes the news every day, raising concerns about the fiscal health of programs such as Medicare and Social Security. But the problem isn’t confined just to the United States; the world’s population is aging as well.
Currently, about 18 percent of the world’s population is older than age 60; by 2050 that number is expected to exceed 22 percent. Very low or declining birth rates in many countries mean that soon, the number of people age 65 and older will be double the number of infants 4 years old and younger—an exact reversal of the situation in 1950.
With aging come a host of healthcare issues. Hypertension, heart disease, arthritis, and diabetes are among the most common, and are often found in combination with each other. How countries are dealing with their aging populations was the subject of Wednesday’s World Opinion Forum, held in conjunction with the International President’s Breakfast during the 2014 AAOS Annual Meeting.
Osteoporotic hip fractures
Setting the stage was Prof. Remi Kohler, representing Guest Nation France, who discussed the challenges of an aging population—which he defined as people older than 80 years—for orthopaedists. Prof. Kohler noted that the number of osteoporotic fractures sustained worldwide will soon reach 6 million annually, and many of them will be osteoporotic hip fractures. One in four elderly patients who sustains a proximal femur fracture will die within 2 years.
According to Prof. Kohler, there are three stages in managing osteoporotic proximal femur fractures: perioperative, rehabilitative, and preventive. Perioperative management should include assessment for various comorbidities, including cardiovascular disease, anemia, diabetes, and cognitive disorders. “A few simple tests such as serum creatinine and blood cell count can provide a good estimate of potential mortality,” he noted. These assessments should be conducted quickly, within 48 hours of injury, to reduce mortality, shorten hospital stays, and lower readmission rates.
The aim of rehabilitation is to reduce the effects of immobilization on bone mineral density, muscle, and fat mass and to help the patient maintain good cognitive and affective functions to avoid mental and social decline. Rehabilitation may last up to 24 months.
Finally, preventive care is needed to reduce the incidence of refracture. After a hip fracture, noted Prof. Kohler, the incidence of new osteoporotic fractures is approximately 10 percent per year. “One of the best fall prevention methods consists of having the patient perform early mobilization exercises to avoid joint stiffness and regain balance when walking. By combining an osteoporosis treatment (D vitamin) with 30 minutes of rehabilitation per day, the risk for a new fracture can be reduced by 30 percent,” he said.
Prof. Kohler called for a close partnership between orthopaedic surgeons and geriatricians and proposed the following three alternatives:
- including a geriatrician as part of a subunit within the orthopaedic department
- establishing a dedicated orthopaedic team to evaluate patients hospitalized in the geriatric units
- providing geriatric consultations for patients hospitalized in the orthopaedic department
Comorbidities and falls
According to Alex Federman, MD, MPH, associate professor of medicine in the division of general internal medicine at the Icahn School of Medicine, Mount Sinai, New York, the prevalence of multiple chronic illnesses, or multimorbidity, is quite high among the elderly. “In the United States, among adults ages 65 to 74 years, 60 percent have three or more chronic illnesses, and that proportion jumps to 75 percent among those older than age 75,” he noted.
“There is a huge constellation of biomedical, socioeconomic, cognitive, and behavioral factors that contribute to the risk of both osteoporosis and falls in older adults,” explained Dr. Federman. One of those behavioral factors is inconsistent use of bisphosphonates to treat osteoporosis. Only 40 percent of adults with osteoporosis continue using bisphosphonates beyond 6 months—regardless of the type of medication or the timing of doses (daily, weekly, or monthly).
As a result, noted Dr. Federman, government, healthcare providers, and insurers are investing heavily in programs that provide comprehensive assessment, management, and support to patients at high risk of poor outcomes.
The Japanese perspective
According to Dr. Yukihide Iwamoto, individuals age 65 and older are the most rapidly growing segment of the population in Japan, accounting for nearly a quarter of the population. The three most common orthopaedic conditions in this age group are spondylolisthesis, knee osteoarthritis, and osteoporosis—and nearly 5.4 million people are afflicted with all three conditions.
As a result, the Japanese Orthopaedic Association (JOA) has launched a public awareness campaign about “locomotive syndrome,” a name the JOA has given to the loss of muscle and balance experienced by many elderly. In 2012, the syndrome was recognized by the government as an issue of concern and media attention is increasing. The JOA has developed a program of exercises that includes squatting and standing on one leg to help combat this syndrome.
View from Argentina
In Argentina, said Dr. Guillermo Bruchmann, three healthcare systems are used—state, public, and private. Although the elderly are covered by a program similar to the U.S. Medicare plan, no national program to address orthopaedic aging issues exists. He noted a need to shorten wait times for individuals to access care and to increase the efficiency of care provided.
Aging in Australia
In the 20th century, noted Prof. Peter Choong, life expectancy in Australia nearly doubled—from 42 years in 1900 to 83 years in 2000. Musculoskeletal conditions, he noted, are the second-largest contributor to disability, and obesity affects nearly a quarter of the population. As a result, joint replacements are increasing and occurring at younger ages, stressing the system and increasing costs.
Australia has a two-tiered healthcare system (public and private) and demand for total joint replacement now outpaces the ability of orthopaedic surgeons to perform them. “We must address the issue of patient selection,” said Prof. Choong. “Too often, our knee-jerk response is to operate, and that needs to change.”
According to its 2010 census, China has nearly 1.7 billion people older than age 60, noted Dr. Tian Wei. Despite the fact that China has several healthcare systems for its population—including socialized medicine, employer-provided coverage, and a government-sponsored program for farmers and peasants—there is an ongoing concern about the overuse of resources and the need to address the increase in chronic diseases.
A best-practice tariff?
During the question-and-answer session, Prof. Timothy Briggs, president of the British Orthopaedic Association, addressed the issue of care coordination between primary care and specialist physicians. He noted that in Australia, patients must be referred to specialists by their primary care doctor in order to receive reimbursement for the visit. He also discussed a “best practice tariff” that would provide additional reimbursement for coordinated care.
“In June,” said Prof. Briggs, “the British Orthopaedic Association and EFORT (the European Federation of National Associations of Orthopaedics and Traumatology) will host its 15th annual congress in London. A major focus of the event will be addressing orthopaedic issues in the aging population, and I invite anyone interested in this topic to attend. For more information, visit www.efort.org/london2014.”
Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at email@example.com